Abstract
Dear Editor,
We commend Snigur et al for addressing a question that spine surgeons confront daily but rarely study with this level of methodological care. 1 Their use of propensity score matching and detailed sagittal measurements elevates the discussion beyond traditional perioperative metrics and provides a valuable foundation for refining surgical decision-making in elderly patients.
One of the most intriguing aspects of the study is the disconnect between radiographic equivalence and higher revision rates in the elderly cohort. The authors interpret this as evidence that older adults maintain sagittal correction as effectively as younger patients, and the data support that conclusion. An alternative interpretation is equally compelling that is surgeons may be implicitly modulating their alignment goals in the very elderly, accepting a “functional alignment” rather than aggressively pursuing full restoration. The trend toward worse preoperative mismatch in the ≥75 group, coupled with minimal postoperative change, suggests that alignment targets may already be age-adjusted in practice. 2 This raises an important question regarding if alignment goals be explicitly age-stratified rather than uniformly applied across decades of life.
The higher revision burden in the elderly despite similar perioperative complication rates deserves particular attention. The modes of failure (pseudoarthrosis, ASD, screw failure) point toward biological and mechanical vulnerability rather than technical shortcomings. This study therefore reinforces that in very elderly patients the challenge is not achieving alignment but sustaining construct integrity over time. Bone quality, sarcopenia, micro-instability, and healing biology likely mediate this vulnerability. 3 The authors’ findings should encourage the community to integrate routine preoperative bone density assessment, Hounsfield unit–based planning, and augmented fixation.
The propensity score matching is a strength, but it also highlights what remains unmeasured. Matching on BMI and comorbidities may have inadvertently selected a physiologically robust subset of elderly patients, limiting generalizability. Frailty indices, cognitive status, functional reserve, and sarcopenia, arguably more relevant to postoperative durability than hypertension or diabetes, were not included. 4
Revision was analyzed as a binary outcome, however, the time-to-revision data hint at a more complex trajectory. Competing risks, particularly mortality, are highly relevant in a ≥75 cohort and may obscure true revision incidence. Even if underpowered here, the study underscores the need for survival-based analyses in future multicenter datasets to distinguish early mechanical failures from late biological ones.
The absence of patient-reported outcomes is a missed opportunity but also a call to action. Radiographic success in the elderly does not necessarily equate to symptomatic improvement, and the relationship between alignment mismatch and quality of life may differ fundamentally with age. 5
Finally, this study offers immediate clinical value. It reassures surgeons that open TLIF can be performed safely in carefully selected patients ≥75, while also providing a realistic framework for counseling about long-term durability. The authors have advanced the conversation from “Can we operate?” to “How do we optimize and counsel?”, a shift that will meaningfully improve shared decision-making.
